Urethral strictures are fairly common in elderly males getting admitted to the intensive care unit. Urethral catheterization is mostly done as a blind procedure and often leads to urethral trauma and, sometimes, false channelization in a patient who is many a time sedated, intubated, and is unable to tell about extreme of pain occurring which could warn the handler. Fluoroscopy is utilized in difficult situations to aid insertion, but this is not always an option for patients in intensive care units. The scope of ultrasonography is expanding in the practice of critical care. We used point-of-care ultrasound to confirm the position of guidewire before dilatation, in order to prevent dilatation of false passage.

Urethral strictures are very common with aging male population. Male catheterization, in particular, can be difficult, especially in patients with enlarged prostate glands or other potentially obstructive conditions in the lower urinary tract.[1] The solutions to problematic urinary catheterization are not well known, and when difficult catheterization occurs, the risk of failed catheterization and concomitant complications increase. Even routine urinary catheter placement may cause trauma and poses a risk of infection.[1],[2] Ultrasound (USG) guidance has been used for suprapubic cystostomy and catheter placement.[3] Transabdominal USG has also been used to check for the tip of the catheter in difficult catheterizations.[4] We report a case where point-of-care USG aided in difficult catheterization.

Case Report

A elderly male patient presented to the triage with a history of breathlessness and fever from 2 days before admission. His comorbidities included chronic kidney disease and coronary artery disease (post-Percutaneous transluminal coronary angioplasty on antiplatelet drugs). Initial arterial blood gas report showed severe metabolic acidosis and severe hypoxia. His immediate management in the medical intensive care included mechanical ventilation and preparation for hemodialysis. Routine USG assessment revealed distended urinary bladder. Immediate catheterization was planned to relieve the distension and for monitoring urine output. Urethral catheterization was attempted using Foley 18F, 14F, and 12F catheters, but failed due to nonpassage of catheter beyond 1–2 cm in the urethra. Urology consult was requested to facilitate the same. Suprapubic catheterization was discussed in view of tight proximal urethral stricture; however, caution was exercised as the patient's family gave a history of the use of dual antiplatelet drugs. He was planned for urethral catheterization over the guidewire. The urology team was concerned about creating a false passage followed by subsequent dilatation of it. Hence, we used point-of-care USG examination of urinary bladder to trace the guidewire in the bladder, which was subsequently followed by localization of graduated dilators and Foley's catheter. A curvilinear probe was placed over the urinary bladder, and the guidewire was localized as sharp hyperechoic structure, which started appearing in the bladder [Figure 1]. Once confirmed, the dilators were passed over it one after another all being confirmed as hyperechoic structures, which appeared larger than the guidewire [Figure 2]. Once dilatation was done, a Foley's catheter was inserted over the guidewire. The wire was retrieved, and the position of the bulb was confirmed using USG [Figure 3].

Urethral strictures can result from inflammatory, ischemic, or traumatic processes, which lead to scar tissue formation; scar tissue contracts to reduce the caliber of the urethral lumen, causing resistance to the antegrade urine flow.[5] Santucci et al. reported that male urethral stricture disease occurred at a rate as high as 0.6% in some susceptible populations and resulted in more than 5000 inpatient visits yearly.[6]

Male urethral stricture is a commonly encountered condition in intensive care unit (ICU) as most of the patients are middle and elderly age group. Chapple et al. reported that 15%–20% of adult men have a stricture.[7] Most penile strictures are iatrogenic (40%) and inflammatory (40%), whereas bulbar strictures are mostly idiopathic (45%) followed by iatrogenic (35%) and traumatic (15%).[8]

Guidewire is prone to go in false passage, coil within the urethera and can also some time coil on itself. Urethral catheterization when done blindly and forcefully by dilating over these guidewires cannot only lead to bleeding but also lead to dilatation of false passage. Suprapubic catheterization under USG guidance is used in cases of stricture urethra with failed attempts to catheterize. In our case, the patient had a very tight stricture, and he was also on regular antiplatelet drugs. This increased his chances of bleeding while attempting suprapubic catheterization and even trying to force the guidewire. We took urology consult and used point-of-care USG to guide us. The technique helped us in relieving the patient's discomfort without subjecting him to iatrogenic complications.

Willette and Coffield[9] have devised an excellent algorithm detailing the steps to be followed whenever a difficult catheterization is encountered in the emergency department. Newer technologies such as catheterization under visual guidance using microendoscope are important tools to help in difficult catheterization. Direct visualization guides catheterization and also help to know size stricture, exact position, and type of stricture. However, these are not readily available at most of the centers. Using USG is not only simple, but also inexpensive. As USG guidance is now being commonly used in ICU for various procedures even in India, it could become a useful method guiding urethral catheterization in urethral stricture, especially in critically ill patients who often are on antiplatelet drugs or have coagulopathy. We did explore PubMed to look for similar case reports. To the best of our knowledge, ultrasonographic guidance has never been used for directing the guidewire and dilatation of urethra. The case report intends to increase the awareness of the readers in the use of a noninvasive technique (USG) to aid difficult urethral catheterization.